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Ann Thorac Surg 2000;70:1647-1650
© 2000 The Society of Thoracic Surgeons

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Original articles: general thoracic

A randomized, controlled trial comparing thoracoscopy and limited thoracotomy for lung biopsy in interstitial lung disease

^a Department of Surgery, McMaster University, Hamilton, Ontario, Canada
^b Department of Medicine, McMaster University, Hamilton, Ontario, Canada
^c Department of Pathology, McMaster University, Hamilton, Ontario, Canada
^d Department of Surgery, University of Chicago, Chicago, Illinois, USA

Address reprint requests to Dr Miller, St Joseph’s Hospital, 50 Charlton Ave East, Hamilton, ON L8N 4A6, Canada
e-mail: jmiller{at}fhs.mcmaster.ca

	Abstract

Top Abstract Introduction Patients and methods Results Comment Acknowledgments References

 
Background. Lung biopsies are frequently needed to diagnose diffuse interstitial lung diseases. A prospective randomized, controlled trial comparing limited thoracotomy (open lung biopsy) and thoracoscopy for lung biopsy was done.

Methods. Ambulatory patients with a clinical diagnosis of diffuse interstitial lung disease were randomized to thoracoscopy or limited thoracotomy. Data on postoperative pain, narcotic requirements, operating room time, adequacy of biopsy, duration of chest tube drainage, length of hospital stay, spirometry, and complications were collected.

Results. A total of 42 randomized patients underwent lung biopsy (thoracoscopy 20, thoracotomy 22). The two study groups were comparable with respect to age, gender, corticosteroid use, and preoperative spirometry. Visual analog scale pain scores were nearly identical in the two groups (p = 0.397). Total morphine dose was 50.8 ± 27.3 mg in the thoracoscopy group and 52.5 ± 25.6 mg in the thoracotomy group (p = 0.86). Spirometry (FEV₁) values in the two groups were not significantly different on postoperative days 1, 2, 14, and 28 (p = 0.665). Duration of operation was similar in both groups (thoracoscopy 40 ± 30 minutes, thoracotomy 37 ± 15 minutes; p = 0.67). The thoracoscopy and thoracotomy groups had equivalent duration of chest tube drainage (thoracoscopy 38 ± 28 hours, thoracotomy 31 ± 26 hours; p = 0.47) and length of hospital stay (thoracoscopy 77 ± 82 hours, thoracotomy 69 ± 55 hours; p = 0.72). Definitive pathologic diagnoses were made in all patients.

Conclusions. There is no clinical or statistical difference in outcomes for thoracoscopic and thoracotomy approaches. Both thoracoscopy and thoracotomy are acceptable procedures for diagnostic lung biopsy in diffuse interstitial lung disease.

	Introduction

Top Abstract Introduction Patients and methods Results Comment Acknowledgments References

 
Lung biopsies are essential for the accurate diagnosis of diffuse interstitial lung diseases [1]. Transbronchial and percutaneous needle biopsy techniques are sometimes useful, but most patients require a surgical biopsy technique [2]. Thoracotomy for open lung biopsy has been a standard surgical approach for many years [1–3]. Recently, the use of thoracoscopic lung biopsies for the diagnosis of diffuse interstitial lung disease has increased [4, 5]. Many comparisons of open (thoracotomy) and thoracoscopic lung biopsy have been done, but all are limited by their retrospective and nonrandomized study designs [6–12]. We undertook a prospective randomized, controlled trial comparing limited thoracotomy and thoracoscopy for diagnostic lung biopsy in diffuse interstitial lung disease.

	Patients and methods

Top Abstract Introduction Patients and methods Results Comment Acknowledgments References

 
Ambulatory patients with a clinical diagnosis of diffuse interstitial lung disease were considered for the study. Patients were enrolled in four centers (McMaster University, University of Chicago, State University of New York at Syracuse, and University of Southern California) between May 1994 and January 1997. Inclusion criteria included radiologic evidence of diffuse interstitial lung disease, ambulatory status, and age greater than 18 years. Exclusion criteria included severe cardiac disease (New York Heart Association class III or IV), contraindication to patient-controlled analgesia (narcotic allergy, drug addiction, or altered mental status), or a pleural space unsuitable for thoracoscopy (previous thoracotomy, pleurodesis, or chest wall or mediastinal deformity). Outcomes of interest included postoperative pain, narcotic requirements, operating room time, adequacy of biopsy, duration of chest tube drainage, length of hospital stay, spirometry, and complications. Informed consent was obtained from all subjects. The Institutional Review Boards of the participating hospitals approved the study protocol.

An a priori sample size of 20 patients in each group was calculated based on an anticipated mean difference in postoperative pain scores of 2.5 cm (on a 10-cm linear analog scale) and an estimated standard deviation of 2.1 cm. Using these estimates the study would have a power of 0.80. Subjects were randomized centrally to thoracoscopy or thoracotomy according to a block-of-four randomization schedule. This was done to prevent one center or surgeon from performing the majority of one of the biopsy techniques as a chance occurrence. Investigators were not informed of the block size to ensure investigator concealment [13].

The thoracic surgical investigators at the various institutions made a concerted effort to standardize surgical techniques. Thoracotomies were 10 to 14 cm in length and anterolateral in position. Single-lumen general anesthesia was used. Surgeons made an effort to minimize rib spreading. The diagnostic wedge resection was done with a linear stapler and the staple line was oversewn if needed. Thoracoscopies were done under general double-lumen anesthesia with patients in the lateral decubitus position. A 10-mm videothoracoscope was used and the ports were positioned at the discretion of the surgeon. The diagnostic lung biopsy was done with an endoscopic stapling device. All patients (thoracotomy and thoracoscopy) had one chest tube (no. 28) placed and connected to 20-cm H₂O suction.

Anesthesia management was identical for both groups with the exception of the type of endotracheal tube used (single-lumen for thoracotomy, double-lumen for thoracoscopy). Preoperative sedation was not given. Volatile anesthetic agents (halothane or isoflurane) and fentanyl (5 µg · kg^-1 · h^-1) were used intraoperatively. All patients were extubated at the end of their surgical procedure. Patient-controlled analgesia pumps of morphine were started in the recovery room. The pumps recorded the amount of morphine delivered.

Postoperative pain was assessed using a 10-cm line visual analog scale (VAS) at 2, 6, 12, 24, 36, 48, 60, and 72 hours after surgery [14]. A VAS pain score was obtained at office follow-up 2, 4, and 12 weeks after surgery. Spirometry (forced expiratory volume in 1 second [FEV₁]) was done before surgery and daily postoperatively (to a maximum of 7 postoperative days). Outpatient follow-up spirometry was done 2 and 4 weeks postsurgery.

Data analysis was done on an intent-to-treat basis. Measured data are presented as means ± standard deviations. Preoperative spirometry volumes are presented as percent of predicted value. Postoperative spirometry values are presented as percentages of the base line value. Parametric data were analyzed with the one-way between-groups analysis of variance (ANOVA). Continuous parametric data such as sequential visual analog scale scores and spirometry were analyzed with the two-way, between-within ANOVA. Nonparametric variables were analyzed with the ² test or Fisher’s exact test. A p value of less than 0.05 was considered significant.

	Results

Top Abstract Introduction Patients and methods Results Comment Acknowledgments References

 
A total of 44 consecutive patients with diffuse interstitial lung disease consented to the study and were randomized. Two patients dropped out after randomization but before the surgical procedures were done; they were excluded. In all, 42 patients underwent lung biopsy (thoracoscopy 20 patients, thoracotomy 22 patients) and completed the study protocol. One of the participating centers (McMaster University) enrolled 70% of the patients. The two study groups were comparable with respect to age, gender, corticosteroid use, and preoperative spirometry (Table 1). There was a nonsignificant trend toward younger age in the thoracoscopy group; this is a manifestation of chance that characterizes randomized trials.

View larger version (22K): [in this window] [in a new window]   Fig 1. Postoperative visual analog scale pain assessment.

View larger version (9K): [in this window] [in a new window]   Fig 2. Postoperative morphine requirements.

View larger version (15K): [in this window] [in a new window]   Fig 3. Postoperative spirometry (FEV1).

A definitive pathologic diagnosis was made in all patients (Table 2). The two biopsy techniques gave equivalent numbers of specimens (thoracoscopy 1.6 ± 0.9 specimens, thoracotomy 1.6 ± 0.7 specimens; p = 0.81), volume of lung tissue (thoracoscopy 11.4 ± 8.7 cm³, thoracotomy 17.4 ± 12.8 cm³; p = 0.12), and weight of lung tissue (thoracoscopy 3.6 ± 3.1 g, thoracotomy 4.8 ± 1.7 g; p = 0.22).

Cost analysis was difficult. Differences in American and Canadian health care systems, currency exchange, and difficulties in obtaining real cost data in the Canadian system were obstacles to accurate cost assessment. Subset analysis of cost data from the American centers was not feasible because of the small patient numbers. A crude estimate of cost for the Canadian patients was done. Thoracoscopy appeared to cost CDN $1000 more than limited thoracotomy.

	Comment

Top Abstract Introduction Patients and methods Results Comment Acknowledgments References

 
Diagnostic lung biopsy for diffuse interstitial lung disease can be accomplished using a limited thoracotomy or thoracoscopy approach [4, 5]. Many studies have compared the two techniques, but all are hampered by their nonrandomized study design [6–12, 15]. Most of the previous nonrandomized studies, including one from the host institution (McMaster University), have suggested some advantage for the thoracoscopic approach [6–10, 12, 15, 16]. Important outcomes that have been assessed include postoperative pain, length of hospital stay, adequacy of diagnostic biopsies, and cost [5]. Several nonrandomized studies have reportedly shown that thoracoscopic biopsies are less painful than biopsies done through a limited thoracotomy [7, 8, 12]. Many nonrandomized studies also show a reduced length of hospital stay for thoracoscopic biopsy procedures [6, 8, 10, 12, 15]. Thoracoscopic lung biopsies are reportedly as adequate, and pathologically accurate, as biopsies done through a limited thoracotomy [6, 9–12, 15]. Several studies have shown an increase in cost for the thoracoscopic technique [8, 11], but higher equipment costs are often offset by reduced costs related to hospital stay [8, 15].

The shortcomings of nonrandomized studies are well known [17]. Assessment of pain and length of hospital stay is especially problematic in nonrandomized studies. Contemporary thoracoscopic cases are often compared to historical thoracotomy cases. With improvements in postoperative pain management and with the recent impetus for earlier hospital discharges, it is not surprising that contemporary thoracoscopic series have better outcomes than historical thoracotomy "controls." In addition, the impact of specific surgeons’ practices is often ignored in nonrandomized studies. Although not stated, the comparison of thoracoscopy and thoracotomy for lung biopsy may really represent a comparison of 2 or more surgeons’ operative results [15]; the study then becomes an assessment of individual surgical skill and practice patterns instead of an objective evaluation of operative techniques. Given the limitations of nonrandomized studies, a randomized controlled trial was needed to compare thoracoscopy and thoracotomy for diagnostic lung biopsy in diffuse interstitial lung disease.

This randomized trial of thoracoscopy or limited thoracotomy for diagnostic lung biopsy in interstitial lung disease showed no difference in postoperative pain, narcotic requirements, operating room time, adequacy of biopsy, duration of chest tube drainage, length of hospital stay, spirometry, or complications. Cost assessment was difficult and no firm conclusion can be made on this issue. The findings of this randomized trial are strikingly different from those of a nonrandomized study from the host institution [15]; this highlights the importance of randomized trials in thoracic surgery [17]. Both limited thoracotomy and thoracoscopic approaches are acceptable choices for diagnostic lung biopsy in diffuse interstitial lung disease.

	Acknowledgments

Top Abstract Introduction Patients and methods Results Comment Acknowledgments References

 
The authors thank L.J. Kohman, MD, and R. McKenna, MD (participating surgeons), L. Vincic, MD (pathology), C. Allen, MB, BCh (respirology), L, Kahn, MD (anesthesia), and C. Goldsmith (statistics) for their participation. This study was funded by a grant from AutoSuture Canada.

	References

Top Abstract Introduction Patients and methods Results Comment Acknowledgments References

 

1. Gaensler E.A., Carrington C.B. Open biopsy for chronic diffuse infiltrative lung disease. Ann Thorac Surg 1980;30:411-426.[Abstract]
2. Burt M.E., Flye M.W., Webber B.L., Wesley R.A. Prospective evaluation of aspiration needle, cutting needle, transbronchial, and open lung biopsy in patients with pulmonary infiltrates. Ann Thorac Surg 1981;32:146-153.[Abstract]
3. Miller R.R., Nelems B., Muller N.L., Evans K.G., Ostrow D.N. Lingular and right middle lobe biopsy in the assessment of diffuse lung disease. Ann Thorac Surg 1987;44:269-273.[Abstract]
4. Krasna M.J., White C.S., Aisner S.C., Templeton P.A., McLaughlin J.S. The role of thoracoscopy in the diagnosis of interstitial lung disease. Ann Thorac Surg 1995;59:348-351.[Abstract/Free Full Text]
5. Ferson P.F., Landreneau R.J. Thoracoscopic lung biopsy or open lung biopsy for interstitial lung disease. Chest Surg Clin North Am 1998;8:749-762.[Medline]
6. Bensard D.D., McIntyre R.C., Jr, Waring B.J., Simon J.S. Comparison of video thoracoscopic lung biopsy to open lung biopsy in the diagnosis of interstitial lung disease. Chest 1993;103:765-770.[Abstract/Free Full Text]
7. Mouroux J., Clary-Meinesz C., Padovani B., et al. Efficacy and safety of videothoracoscopic lung biopsy in the diagnosis of interstitial lung disease. Eur J Cardiothorac Surg 1997;11:22-26.[Abstract]
8. Carnochan F.M., Walker W.S., Cameron E.W. Efficacy of video assisted thoracoscopic lung biopsy. Thorax 1994;49:361-363.[Abstract/Free Full Text]
9. Kadokura M., Colby T.V., Myers J.L., et al. Pathologic comparison of video-assisted thoracic surgical lung biopsy with traditional open lung biopsy. J Thorac Cardiovasc Surg 1995;109:494-498.[Abstract/Free Full Text]
10. Ferson P.F., Landreneau R.J., Dowling R.D., et al. Comparison of open versus thoracoscopic lung biopsy for diffuse infiltrative pulmonary disease. J Thorac Cardiovasc Surg 1993;106:194-199.[Abstract]
11. Molin L.J., Steinberg J.B., Lanza L.A. VATS increases costs in patients undergoing lung biopsy for interstitial lung disease. Ann Thorac Surg 1994;58:1595-1598.[Abstract]
12. Ravini M., Ferraro G., Barbieri B., Colombo P., Rizzato G. Changing strategies of lung biopsies in diffuse lung diseases. Eur Respir J 1998;11:99-103.[Abstract/Free Full Text]
13. Schulz K.F., Chalmers I., Hayes R.J., Altman D.G. Empirical evidence of bias. Dimensions of methodological quality associated with estimates of treatment effects in controlled trials. JAMA 1995;273:408-412.[Abstract/Free Full Text]
14. Jensen M.P., Karoly P., O’Riordan E.F., Bland F., Jr, Burns R.S. The subjective experience of acute pain. An assessment of the utility of 10 indices. Clin J Pain 1989;5:153-159.[Medline]
15. Miller J.D., Julkarni M.G., Young J.E.M., Bennett W.F. Video assisted or open-lung biopsy for the diagnosis of diffuse lung disease. Chest 1994;106:60s.
16. Ferguson M.K. Thoracoscopy for diagnosis of diffuse lung disease. Ann Thorac Surg 1993;56:694-696.[Abstract]
17. Law S., Wong J. Use of controlled randomized trials to evaluate new technologies and new operative procedures in surgery. J Gastrointest Surg 1998;2:494-495.[Medline]

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